1. Chapter 12
Liver Transplantation 1
Orthotopic liver transplant, acute (cellular) rejection, markedly active (RAI = 8 of 9)
Case 12.1

2. Clinical Presentation12
Liver Transplantation 2
Clinical Presentation
A 46-year-old man with cirrhosis secondary to chronic hepatitis C (most likely acquired from blood transfusions after a car accident in Mexico), esophageal varices, encephalopathy, and ascites underwent a liver transplant.
Post-transplant liver biopsies did document recurrent HCV.
He presented about 10½ months post-transplant with jaundice and markedly elevated transaminases in the 1200 range, with hyperbilirubinemia, and underwent a liver biopsy to rule out rejection versus recurrent HCV.

3. 12
Liver Transplantation 3
Pathology
All of the portal tracts were markedly expanded by a mixed infiltrate consisting of lymphocytes, histiocytes, immunoblasts, and numerous eosinophils (a).
Figure 12.1(a)

4. 12
Liver Transplantation 4
Pathology
High power showed interlobular bile ducts surrounded and focally infiltrated by lymphocytes, with numerous eosinophils also present within the portal tracts (b, c).
Figure 12.1(b)
Figure 12.1(c)

5. Pathology 12 5 Liver Transplantation Figure 12.1(d)
The terminal hepatic venules showed endothelial inflammation (endothelialitis), with the inflammatory cells also spilling out into the perivenular zone (d); some of the portal venules also showed endothelial inflammation.
No portal lymphoid aggregates, periportal interface inflammatory activity, or steatosis was present.
Figure 12.1(d)

6. 12
Liver Transplantation 6
Diagnosis
Orthotopic liver transplant (OLT), acute (cellular) rejection, markedly active, rejection activity index (RAI) = 8 of 9 (approximately 10½ months post-transplant)

7. 12
Liver Transplantation 7
Comment
The aminotransferase values in both rejection-mediated injury and disease recurrence can be quite elevated in spite of only mild necroinflammatory changes seen on biopsy, and vice versa; as the lab tests can be unpredictable in assessing the liver disease at any one point in time, liver biopsy remains the gold standard for treatment approaches in many instances.
In the present case the perivenular inflammation related to the rejection process was a most likely contributor to the high AST and ALT values.

8. 12
Liver Transplantation 8
Comment
It is oftentimes difficult to exclude a coexisting recurrent liver disease when acute rejection is marked.
The absence of (1) portal lymphoid aggregates, (2) steatosis in the lobules, and (3) periportal activity are against but do not totally exclude some degree of recurrent HCV in this case example, especially since previous biopsies did indeed document recurrent HCV.